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Mentoring Partnership Application

Due to the number of qualified applicants who are sincerely committed to this work and our limited availability of
time for high quality mentoring relationships, we must select only applicants we feel will benefit most from this
association. Please understand that we support and appreciate your interest and regret that acceptance to this
program must be restricted.

Step 1 of 3

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Name*

FirstLast

Email*

Work Phone*

Cell Phone

Leave blank if you prefer us not to call your cell

Are you a...?**

Practicing clinician

Graduate student

How long in practice:*

How long with PPD clients*

Where are you studying?*

Date of graduation:*

Have you completed the PPSC Post-Graduate Training Program?*

Yes

Pending

No

Please list the dates:*

Please Explain*

List any classes, seminars, workshops or training that you have completed that prepare you for participation in this program?*

What do you think makes you a good candidate for this program?*

What personal goals do you hope to achieve through this program?*

Is there anything else you would like us to know?

What is your primary reason for participating in the program?*

Would you be interested in observing an initial assessment at the PPSC if that is geographically feasible?*

I understand that all mentoring consultations are professional commitments and I agree to provide 24 hrs notice prior to any cancellation. Payment for consultations will be made in a timely fashion upon receipt of services, whether in person or on the phone. If these conditions are not met, the PPSC reserves the right to discontinue mentoring sessions.

Please state that this information has been submitted by you and it is correct:*

*Any and all information on this website has been designed for personal use for individual women and their families and for individual clinicians. If organizations or agencies are interested in the use
of any or all PPSC materials on this website for educational or training purposes, please contact the PPSC for license agreement information.